Denied

Ok now what?  I have been denied by Cigna due to the fact that my BMI was too low for 2004 & 2005.  I need this surgery and want suggestions on an appeal.  PLEASE HELP!

I am so sorry to hear about your denial.  I was denied also and it really sucks!  But you know, it will show you how bad you really want the surgery and get you to fightin for it!  I don't know about the bmi in 04, 05.  The only thing I could suggest is to get hold of your policy and find out exactly what the medical necessity requirements are.  Does it actually state that your bmi has to be a certain number for so many years?  I would probably call the doctor's office where you are trying ot get it approved and ask them for some advice, and if they have dealt with this before.  I have heard of being denied for not having records of diet attempts for so many years, but not bmi....  Sorry! Good luck to you. Please keep us posted.

Lisa Sorry for your bad news. C'ya Bob

Sorry you were denied, but don't give up. What about co-morbidities?Most insurance companies take them into consideration and accept  lower BMI with one or more co-morbidities, such as diabetes, heart problems, edema, sleep apnea, etc.  Maybe a letter from your Doc might help.  Hang in there!

Well I have high blood pressure, polycystic ovarian syndrome, insulin resistance, stasis dermatitis in lower legs from swelling, acid reflux, and only one thyroid.  Is that not enough regardless of my BMI 4 years ago. 

By the way BamaBob I also have a fatty liver.

Comorbid conditions   Life-threatening health problems arise from obesity as a consequence of its mechanical or metabolic effects. These comorbidities may in turn lead to severe deterioration of health, shortened life expectancy, and lower quality of life.

Major comorbidities include:

• Atherosclerotic cardiovascular disease. Obesity is not only associated with the occurrence of hypercholesterolemia and hypertriglyceridemia, but it is also a factor in the occurrence of atherosclerosis, the deposition of fats within the walls of the blood vessels. This leads to conditions such as coronary artery disease, congestive heart failure, and "hardening of the arteries." This group of conditions is a leading cause of death in the United States.
• Diabetes mellitus type 2 occurs mostly in middle and old age, but it is up to 40 times more likely in those who are severely overweight. It is associated with ASCVD, kidney failure, blindness, nerve damage, and amputations of the extremities, and is also a leading overall cause of death in the United States. Dysmetabolic Syndrome X, a pre-diabetic condition often associated with obesity, is accompanied by elevated levels of insulin in the blood and a high incidence of early development of coronary heart disease.
• Essential hypertension or "high blood pressure", is much more common in obese individuals. It can lead to early development of ASCVD, as well as to kidney disease. Weight loss is considered to be an important feature of treatment.
• Obstructive sleep apnea (OSA) Persons with this condition tend to suffer from airway obstruction when asleep, as the muscles relax and the weight and bulk of tissues collapses the throat passages. An observer notices loud snoring, frequent periods when breathing ceases (apneas), and episodes of restlessness and partial awakening. The afflicted patient is often unaware of the nature of the problem, but may notice frequent awakening at night, dry mouth, a sense of having slept poorly, daytime drowsiness and fatigue, or inappropriate sleeping (such as at work, in meetings, or while driving). This condition has a significant associated mortality.
• Gastroesophageal reflux disease (GERD) is characterized by regurgitation (reflux) of acid and gastric contents into the esophagus, and sometimes into the back of the throat. Gastric acid and bile are very corrosive to the lining membrane of the esophagus, and cause it to become inflamed (esophagitis) and sometimes scarred (esophageal stricture). Reflux which occurs while sleeping can lead to sudden coughing and choking at night, a burning sensation in the throat (pyrosis), and inhalation of acid and stomach contents into the lungs, with the risk of hoarseness, bronchitis, pneumonia, lung abscess and lung scarring. GERD is often associated with development of asthma, and causation of asthmatic attacks, and may also be aggravated by OSA.
• Gallbladder disease is much more likely in obese individuals, being associated with formation of gallstones, usually composed of crystallized cholesterol, within the gallbladder. Although readily treatable by removal of the gallbladder (cholecystectomy), it may lead to life-threatening problems such as obstruction of the ducts from the liver, jaundice, and inflammation of the pancreas (gallstone pancreatitis).
• Liver disease is present in some degree in 90% of persons who undergo bariatric surgery, usually a manifestation of the metabolic effects of obesity on the liver. This may take the form of large fat globules within the liver cells (steatosis), chronic inflammation of the liver (steatohepatitis), and in a few instances, cirrhosis of the liver. The latter condition may lead to liver failure and the need for a liver transplant.
• Venous thromboembolic disease affects the legs, and causes swelling, thickening and discoloration of the skin, and ulceration of the skin. This condition begins with damage to the veins of the legs, associated with formation of blood clots (thrombophlebitis), often associated with an injury, a pregnancy (even use of birth-control pills or hormones), or a surgical operation. When a newly formed blood clot breaks loose, and floats through the veins to the heart and lungs, it is called a Pulmonary embolus, which may sometimes be fatal within minutes. More commonly, the blood clot remains in place locally, and heals by becoming a scar, which permanently damages the vein. Once damaged, the veins cannot fully function to return blood to the heart, and increased venous pressure in the legs causes swelling, impaired circulation in the skin, and sometimes skin breakdown. Obesity is a major risk factor in development of VTE, and may also aggravate the increased venous pressure in the legs.
• Degenerative disc disease is a progressive "wearing-out" of the cartilaginous disks between the vertebral bones of the spine. It occurs more often and earlier in life in obese persons, due to the markedly increased mechanical stress on the disks from the extra weight. Its most common sign is chronic low back pain, which may be disabling. This condition is also associated with sciatica, lumbar spondylosis, and spinal stenosis.
• Degenerative disease of the weight bearing joints, or osteoarthritis, affecting the hips, knees, ankles and feet, occurs earlier in life, and in greater degree, in obese individuals, due to the mechanical stresses of excess weight. Joint pain, loss of mobility, and joint replacement surgery are much more likely in obese persons.

Surgical indications
Gastric bypass is indicated for the surgical treatment of morbid obesity, a diagnosis which is made when the patient is seriously obese, has been unable to achieve satisfactory and sustained weight loss by dietary efforts, and is suffering from co-morbid conditions which are either life-threatening or a serious impairment to the quality of life.

In the past, serious obesity was interpreted to mean weighing at least 100 pounds (45 kg) more than the "ideal body weight", an actuarially determined body weight at which one was estimated to be likely to live the longest, as determined by the life insurance industry. This criterion failed for persons of short stature.

In 1991, the National Institutes of Health sponsored a consensus panel whose recommendations have set the current standard for consideration of surgical treatment, the body mass index (BMI). The BMI is defined as the body weight (in kilograms), divided by the square of the height (in meters). The result is expressed as a number usually between 20 and 70, in units of kilograms per square meter.

The Consensus Panel of the National Institutes of Health (NIH) recommended the following criteria for consideration of bariatric surgery, including gastric bypass procedures:

1. People who have a body mass index (BMI) of 40 or higher. Or,
2. People with a BMI of 35 or higher with one or more related comorbid conditions.

The Consensus Panel also emphasized the necessity of multidisciplinary care of the bariatric surgical patient, by a team of physicians and therapists, to manage associated co-morbidities, nutrition, physical activity, behavior and psychological needs. The surgical procedure is best regarded as a tool which enables the patient to alter lifestyle and eating habits, and to achieve effective and permanent management of their obesity and eating behavior.

Since 1991, major developments in the field of bariatric surgery, particularly laparoscopy, have outdated some of the conclusions of the NIH panel. In 2004, a Consensus Conference was sponsored by the American Society for Bariatric Surgery (ASBS), which updated the evidence and the conclusions of the NIH panel. This Conference, composed of physicians and scientists of many disciplines, both surgical and non-surgical, reached several conclusions, amongst which were:  

Bariatric surgery is the most effective treatment for morbid obesity
Gastric bypass is one of four types of operations for morbid obesity.
Laparoscopic surgery is equally effective and as safe as open surgery.
Patients should undergo comprehensive pre-operative evaluation, and have multi-disciplinary support, for optimum outcome.
 

Insurance co's don't consider PCOS or Metabolic X (aka Insulin Resistance) as comorbidities.  I think they should, but they do not.  Unless you have a good insurance plan.

Im sorry to hear about your denial, and denied because of a low BMI 4 yrs ago?  thats a new one.  Dont give up, call your doctor, and ask him to write a letter to the insurance co.  you could also write a letter to them, explaining your comorbidities, and why its so important to you.  Just dont give up.  Sometimes it takes 2 or more tries to be approved.  Good luck! 

Sorry to hear about your denial. I was denied the 1st time as well so I understand how you are feeling. Does your plan require that you have a certain BMI for 5 years? And are you saying that you did not have a high BMI until 2006? What about before 2004 - did you have a high BMI then or it just started in 2006? I would contact your Drs office and write an appeal letter. They can state that although you did not have a high BMI in 2004-2005 that your BMI now falls into the obese category and that you medically need this surgery.  That waiting for 2-3 more years could cause serious medical  conditions. Don't give up. Keep fighting for it. I think insurance companies want you to give up. Good luck with your approval.